Corinne Haslam
21 Jul 2023 · Coroner Chris Morris · Manchester South
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of mental health ward access to physical health specialists
“The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department”
2. information silos between mental and physical health
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems”
3. lack of VTE risk assessment guidance
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
This report
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa),”
Closely relatedConfidence 0.90 · high
Earlier report
“There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts.”
This report
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems.”
Identical hazardConfidence 0.90 · high
Earlier report
“Hospital and Mental Health Liaison staff are working with different | computer-based records systems.”
This report
“Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems.”
Closely relatedConfidence 0.90 · high
Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
This report
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated.”